Provider Demographics
NPI:1629581855
Name:JOHNSON, RACHAEL VIRGINIA (PA-C)
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:VIRGINIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 N FAIRFIELD AVE APT 310F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-7127
Mailing Address - Country:US
Mailing Address - Phone:347-432-0788
Mailing Address - Fax:
Practice Address - Street 1:1935 N FAIRFIELD AVE APT 310F
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-7127
Practice Address - Country:US
Practice Address - Phone:347-432-0788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical